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Vermont: Patient Registry and Tracking System

Through the Vermont Blueprint for Health, a public–private initiative to improve chronic care, Vermont is creating a patient registry to track patient medical conditions and treatments, guide chronic care treatment decisions, and measure health outcomes at the group and individual levels.[1]

"The goal is to promote individualized, guideline-based care for each patient and for a practice's population as a whole," says Craig Jones, director of Blueprint for Health. The patient registry will have three main functions:

  • Treatment guidance at time of visit: using lab results, diagnoses, and other patienst information, the tool helps steer treatment decisions by offering evidence-based care guidelines covering 300 conditions. It provides health maintenance protocols, alerting practitioners to patients in need of care or who are noncompliant, and helps plan and schedule visits and lab work;
  • Electronic prescribing:The tool forwards the prescription to the pharmacy, enters it immediately into the patient's record, checks for allergies and drug interactions, and gives guidance regarding dose, intervals, and other issues. E-prescribing has been shown to reduce medication errors and improve patient compliance; and
  • Flexible reporting capability: enables care teams to produce reports of patient outcomes at the group level that can be used to coordinate care and follow-up, and to compare performance against nationally accepted standards.

The tool was created by DocSite, an information technology firm, and funded through the state-appropriated Blueprint for Health budget. It has been introduced at the first of three pilot communities that are developing patient-centered medical homes, supported by locally based, multidisciplinary care coordination teams, called Community Care Teams. Five medical practices, including a hospital-based clinic and four Federally Qualified Health Centers, are involved in this first pilot community. The Blueprint for Health program, Vermont Medicaid, and the state's three commercial insurers are participating by enhancing payments to these practices and sharing the costs of the Community Care Team.

The registry will be rolled out to two additional pilot communities this fall, as well as to a few other communities interested in and deemed capable of participating. An evaluation will determine next steps for dissemination, but the hope and expectation is to extend the registry throughout the state.

The patient registry is one of many health information technology initiatives Vermont is pursuing. The Blueprint for Health is supporting development of a Health Information Exchange with Vermont Information Technology Leaders, the state's Regional Health Information Organization, whereby information from physician office electronic health records (EHRs), hospitals, and other sources will feed into a centralized repository. In addition, the state has established a health information technology fund, which will support EHR adoption in physician practices, among other initiatives.

Jones admits that many challenges lie ahead, particularly in linking all of the necessary data feeds into a centralized exchange. He adds that, "the ultimate goal is to expand and integrate EHRs, the patient registry, and the exchange to support quality improvement throughout the public and private health systems in Vermont."

[1] The Blueprint for Health is a public–private partnership administered through the Vermont Department of Health. The $4.8 million annual budget (funded through taxes) covers staff at the Health Department and funds six communities implementing reforms at the local level, as well as evaluation, health information technology, and other items.

For More Information on the Vermont Clinical Tracking System
See: Vermont Department of Health Web Site
Contact: Lisa Dulsky Watkins, M.D., Assistant Director, Vermont Blueprint for Health, [email protected]

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